a comparative study on the risk factors of musculoskeletal

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A Comparative Study on the Risk Factors of Musculoskeletal Disorders among

Laparoscopic Surgical Technologists in Circulatory and Scrub Roles

Golchin Shahijani

Faculty of Nursing and Midwifery

Isfahan University of Medical Sciences Hezar Jerib street, Isfahan, Iran 8174673461

Phone: +98 31 3792 3071

Mahnaz Shakerian

Department of Occupational Health

Shiraz University of Medical Science Central building of Shiraz University of Medical Sciences, Zand St., Shiraz, Iran

PO Box: 71348-14336

Ahmad Ghadami

Nursing and Midwifery Care Research Center, Faculty of Nursing and Midwifery

Isfahan University of Medical Sciences Hezar Jerib street, Isfahan, Iran 8174673461

Phone: +98 31 3792 3071 [email protected]

Abstract

Background: Musculoskeletal disorders are of the most important occupational injuries and

diseases, in which the work environment and individual activities play an essential role in their

prevalence. Since laparoscopy has become a preferred approach to treating many of the actions, the

aim of this study was to determine the risk factors of musculoskeletal disorders among laparoscopic

surgery technologists and comparing them between circulatory and scrubbing roles.

Materials and Methods: In this descriptive-analytical cross-sectional study, 49 participants

were evaluated by REBA method in Al-zahra Hospital, Isfahan, Iran, 2017. Data was collected

through REBA form and analyzed using SPSS software version 20. Results: 94% of our samples

were women mostly married with an age range of 32/17 years. The prevalence of musculoskeletal

disorders was 98.87% with a mean overall risk of 7.2 ± 0.75 in the role of circulatory and 5.31 ±

0.63 in the role of scrub.

Conclusion: Considering the fact that surgical technologists are at risk due to the nature of

their job and to promote their health, ergonomic interventions are critically suggested for

equipment, tools and environments as well as including ergonomics in their educational curriculum

and regular exercise programs.

Keywords: Musculoskeletal Disorders; Risk Factors, Postures; Laparoscopy; Circulatory

and Scrub.

1. Introduction

Laparoscopic techniques for minimally invasive surgery (MIS) are rapidly developing (Janki

et. al., 2017; Bartnicka et. al., 2013) so that it might have been considered as the first choice for

many surgeries such as cholecystectomy And has become a golden standard for removal of the

gallbladder (Janki et. al., 2017; Bartnicka et. al., 2018; Kramp et. al., 2014). Although there are many

advantages in laparoscopic procedures such as less pain after surgery, shorter recovery time and

better results for patients (Janki et. al., 2017; Bartnicka et. al., 2018; Choi et. al., 2018), they require

a fixed port position contributing to different awkward postures (El-Badry et. al., 2018) and certain

technical constraints (Sánchez-Margallo et. al., 2017). There may be ergonomic problems, therefore,

BRAIN – Broad Research in Artificial Intelligence and Neuroscience

Volume 10, Special Issue (June, 2019), ISSN 2067-3957

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with techniques or tools (Bartnicka et. al., 2018). Among health workers, especially nurses, Work-

related Musculoskeletal Disorders (WMSDs) are a major global concern (Nur Azma et. al., 2016)

and the number of cases has risen since 1980 (Athena et. al., 2014). For example, the number of

WMSDs complaints in Taiwanese nurses, has gone up from 28.35% in 2006 to 33.65% in 2010

(Chung et. al., 2013). Also, based on the statistics, the reported complains among nurses who

experienced WMSDs symptoms at least in one region of their body were 88% in Malaysia, (Nur

Azma et. al., 2016), 48% in the United States (Zhang et. al., 2018), 85% in Saudi Arabia (Attar.,

2014), 66% in Switzerland (Nützi et. al., 2015), 80.8% in Africa 80.8% (Munabi et. al., 2014), 100%

in Iran (Zamanian et. al., 2017). The cost of these disorders is estimated about 4% of the world's

gross domestic product. For instance, back injuries among the operating room staff have caused

direct costs of $ 37,000 and indirect costs of $ 147,000 (King, 2011). In addition, ignoring the risk

factors and injuries of musculoskeletal disorders over time, it may result in increasing absenteeism,

medical expenses, pre-retirement, and reducing the working quality and productivity, as well as the

lack of workforce, abundant economic effects on individuals, organizations, and societies or even in

more severe cases the death of a person (Ballester Arias & García, 2017; Taghinejad et. al., 2015).

Therefore, by assessing the WMSDs risk factors, high risk tasks can be identified and it may be

possible to eliminate or reduce these risk factors through ergonomically designing the layout

(Choobineh et. al., 2013; Choobineh et. al., 2012), tools and equipment (Choobineh et. al., 2012)

contemporary with an organized educational intervention (Copenhaver et. al., 2017; Epstein et. al.,

2018) with the aim of adopting suitable work postures (El-Badry et. al., 2018; Abdollahzade et. al.,

2016), exercise (Stolt et. al., 2018; Heba et. al., 2018) aerobics and physical strength training (Szeto

et. al., 2013; Wang et. al., 2017) prevented the spread of it (Dana et. al., 2013; Wang et. al., 2017). As

previously mentioned, laparoscopic approach encompasses unique ergonomic challenges compared

to open surgery (Wang et. al., 2017). Although, some studies have shown a relationship between

laparoscopy and more musculoskeletal pain in surgeons (Dalager et. al., 2018; Choi, 2015), some

other studies like Wang Robert et. al. (2017) a reduction of ergonomic stress was observed in some

muscles among surgeons doing laparoscopic practice compared with that of open surgery (Wang et.

al., 2017). However, there is no detailed ergonomic information on the impact of this new

technology on the activities of surgical technologists during laparoscopic surgery since so far few

studies have been conducted specifically on these people, especially in the role of Circular. In the

surgical team, surgical technologists are only part of the team with two different roles of circulatory

and scrub among surgical operations. They in surgical procedures of most medical centers, the

surgical technologists would act as a circulatory, the interface between the surgical sterilization

team and the non-sterile environment (Choobineh et. al., 2010) and in the role of scrub, they act

simultaneously as scrubs and as the first assistant throughout the entire course of surgery which

means, ergonomically working in worse situation than even nursing.

So, Although new technology may yield credible advantages for surgical team like

improving patient surgery outcomes (Dalager et. al., 2017) or even reducing the risk of transmitting

biological agents; it is unclear in terms of ergonomics what impacts would have on the person with

the role(s) of the circulatory and/or scrub. Based on the mentioned points, the need for a study with

regard to the risk factors leading to WMSDs is felt among these people. Therefore, this study aimed

at comparing the WMSDs risk factors among laparoscopic surgery technologists with the two roles

of circular and scrubbing.

Laparoscopic History

Laparoscopy goes back to 1901 (Supe et. al., 2010), the first laparoscopy in Alzahra hospital,

however, dates back to 1995, firstly done by attend Thorax on laparoscopic cholecystectomy.

Today's other operations such as herniorrhaphy, bariatric, diagnostic laparoscopy,

hysterectomy, cystectomy, thymectomy, pulmonary, nephrectomy, and diagnostic Infertility have

also been developed. Cholecystectomy in the studied hospital is performed based on the American

method, i.e. the surgeon standing on the left side of the patient (Kramp et. al., 2014), through 4

G. Shahijani, M. Shakerian, A. Ghadami - A Comparative Study on the Risk Factors of Musculoskeletal Disorders among


91

separate ports with Trendelenburg reversal of the patient after pneumoperitoneum with an average

time of 103 minutes (from patient arrival to departure).

Ergonomic Problems

The advent of Minimal Invasive Surgery (MIS) has changed the environment of today's

operating rooms (Wasielewski et. al., 2017). These operating rooms, which are originally designed

for open surgical operations, are not responsive to large equipment used in laparoscopic devices.

Although the laparoscopic method has currently become a preferred approach to many practices, the

shortage of laparoscopic equipment is critically felt as in the 11 rooms where laparoscopic surgery

takes place; only 7 tray Carts exist containing laparoscopic equipment (monitor, insufflator, cold

light source, DVD and CCD drawer). These carts are, inevitably, kept outdoors and away from the

operating room contributing to personnel’s obligation to relocate, reconnect, and reassemble these

equipment for each operation. The 6 monitors available include one very low qualified 14 inch, two

ordinary 20 inch and four fairly good qualified flat monitors permanently located on the highest

floor of each card. The heights of the monitor center to the ground are 1640, 1665, 1680, 1750 mm

in the ordinary and flat ones, respectively. The CCD drawer is also placed on the lowest floorboard

with a height of 280 and 230, 470, 490 mm from the floor. despite open operations through which

only a pack and a set are required, laparoscopic cholecystectomy needs more widespread sets and

dishes Including at least one pack cloth (6900 kg) or disposable (approx. 200 g), a small set (2700

g) or a large general (3900 g) dish of homolog handhold (6200 g) laparoscopic dish (6200 g) dish

hook and lens (3900 g) and sometimes also dishes of advance (6900 g), the trocar dish (3600 g) and

the additional instrument dishes (6100 g). These dishes are also kept in the workroom at a height of

1880 mm from the ground floor and at 5 floors away from the main operating room.

Sets (small and general) and packs (fabric and disposable) are also located in the hall away

from the rooms and have the heights of 1040, 830 and 1150,230 mm from the floor, respectively,

(Figure 1).

Figure 1. Sets and packs are located in the hall away

The hospital surgical beds are of the two types of manual and automatic with the minimum

and maximum adjustable heights of 750- 970mm and 700-1000 mm, respectively, adjusted to the

surgeon.

The laparoscopic instrument used in cholecystectomy, including Scissor (length 470 and

455 mm), Clip applier (455, 460 and 470 mm), Grasper 470 mm, hook 355 mm, lens and CCD

altogether were (395+1353 = 530 mm) (Figure 2).



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Figure 2. The laparoscopic instrument used in cholecystectomy

To use electro cautery and Ligasure for a dissection, cut and coagulate tissues, a foot pedal

should be placed on the floor where the surgeon is standing.

To make an appropriate lighting of the operation field, before and after using the camera,

the ceiling-connected siliatic lights are applied. Depending on the presence of one or two residents,

the scrub can be placed either on the left or right side of the patient. Since the monitor is adjusted to

be placed on the right side of the patient depending on the surgeon location, the distances between

the surgical technologist's eye to the center of the image on the right or left are 774 and 1372 mm,

respectively, and the average distance between the elbow of the scrub to the ground floor is 1005

mm. The minimum distance traveled by a surgical technologist in each operation include: 18

surgical room to a stoke Set and Pack 42 steps, patient admission 172steps, the pharmacy 118 steps,

workshop 148 steps, Recovery for sample delivery 282 steps, record patient profile in the book 20

steps and computer out of the room 32 steps, scrub sink 116 steps, computer in the room 10 steps,

set Sialtic light 12 steps, the cautery and the suction device 20 steps, Connect the serum 12 steps,

pouring formalin solution 22 steps and unpacking the inside of the commode each is 18 steps

2. Methods

2.1. Participants and Procedures

This study is descriptive analytical and cross-sectional performed after obtaining the code of

ethics from Isfahan University of Medical Sciences from March2017 to July 2018, at al-Zahra

Hospital ,Isfahan, Iran. A written consent was given to the participants to partook in the study for 5

months.

The study population included 57 (50 females and 7 males) of laparoscopic technologists in

the hospital voluntarily enrolled in the study. After considering inclusion criteria (participation in

laparoscopic cholecystectomy in scrub and circulatory roles, voluntary and satisfactory partaking in

the research, not having any musculoskeletal disorder and history of bone or joint surgery and no

pregnancy) and exclusion criteria(The participants dissatisfaction with continuing cooperation,

inactivity in the laparoscopic field, reluctance to take photos, leaving and death), 8 people were

excluded from the study and 49 people partook in this study to be evaluated at least 2 times and up

to 4 times(139 scrub role and 149 circular role).

2.2. Data Collection and Procedure

Initially, the researcher made a list of the most important tasks performed by the circular

[bringing pack and surgical sets, opening sterile instruments on the surgical table, pushing or

pulling equipment, attaching the delivery of scrub connectors to the corresponding devices(cautery

pen, cord, serum set , etc.), Delivery of instrumentation and materials to the surgical team (Cautery

Pedal and CCD), patient relocation] and scrub [delivering sterile instruments from the circulatory,



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surgical table setup, pulling up the surgical table, helping the surgeon in the field of operation and

delivery of dirty tools used to operate the workroom] pre prepared.

In the following days, a two-part general Nordic questionnaire was used containing

demographic information (age, gender, weight, height, dominant hand, regular exercise, level of

education, work experience, marital status, ergonomic awareness, job satisfaction, visual

requirement, satisfaction from the monthly program and the operating room's agent).

The following tool were used to evaluate the persons:

REBA: An observational method validated and verifiable used to assess the health jobs

work statuses.

To evaluate the circulatory (by the researcher) and the scrub (by the occupational health

professional) in the tasks determined by rapid entire body assessment, with a digital camera Sony

HX1, One or more photos of each task are provided. Then the REBA checklist was scored; also,

force exertion rating score (less than 5 kg = 0, 10 kg = 1 and more than 10 kg = 2), hand pairing

with load score (load with proper handle = 0, acceptable with hand = 1, unacceptable with hand = 2

and load without handle with inappropriate postures = 3) and activity type (static or dynamic = 1)

were involved. Finally, the other person who did not know the details of the checklist for

interpretation in the course of the work and the research objectives entered the REBA software.

Score 1: negative level of risk that no corrective action is required. 2 to 3: low risk level, further

studies are required. 4 to 7: moderate level of risk and corrective action is required.

There are 8 to 10 levels of risk that corrective actions should be implemented in the near future. 11

to 15 levels are very high and immediate ergonomic action is required (Pazouki et. al., 2017).

2.3. Data Analysis

The research data were both quantitative (continuous and consecutive) and qualitative

(nominal) and were analyzed using SPSS 20 software. In order to determine the overall risk score of

musculoskeletal disorders in the role of scrub and circulatory, descriptive statistics (Mean, standard

deviation, percentage and frequency) was applied. For comparing the scores of the two tasks, paired

t-test was used. A repeated measure of variance analysis was applied to determine the average risk

score in each of the tasks by separating the circular and scrub roles (after assuring that the

assumption of sphere was determined by the Makhli test). Then, using the LFB test, two tasks were

compared. Finally, we used independent T-test to determine the distribution of musculoskeletal

disorders and the comparison of the mean overall risk score of circulatory and scrub.

3. Results

3.1. Sample Characteristics

Approximately 94% of the research population was women (46 women, 3 men). The

participants aged 23 to 48 years (mean 32.17±64.6) with mean height and weight was 163.8 and

61.8, respectively. Most of the participants were right-handed (83.7%) and job tenure ranged from

1 to 25 years (9.26± 6.2). 68.8 % of them were married and 79.6% had no regular exercise.

3.2. Working Postures

The average RBA score for all of the evaluated activities was obtained higher than 6 (Table 1).

Also, the task of the instrument delivery to the surgical team (foot pedal) had the highest

score of 9.29± 1.25 (P <0.001) and the task of patients transfer had the lowest score of 6.4± 1.43 (P

<0.001). Based on the score obtained from the scrub tasks shown in Table (2); It was found that the

RBA score was between 4 and 6. The lowest score for surgical operation was 4.3± 1.11 (P <0.001),

and the highest score for delivery of the surgical instrument used in the work room was 6.1 ± 1.2 (P

<0.001). Based on the results, (Tables 1 and 2), it was found that the average risk score was

significantly different between some tasks of circular and (P <0.001) in a way that the greatest



94

difference was observed between pedal delivery and patient displacement tasks (P <0.001). Also,

the results (table 3) showed that the average overall risk score in the circulatory tasks was higher

than that of the scrub (P <0.001).

Table 1. Determining and comparing frequency distribution gender in two groups

Duties Average RBA

score Standard

deviation F- value P- value Difference between

two tasks 1. Bringing Surgery Set

and Pack Surgery

6.55

1.43

46.8

< 0.001 1 2 0.2 3 -2.67 4 0.81

5 -1.1 2. Open sterile instruments

6.35

1.14

46.8

< 0.001

6 0.41

2 3 -2.87 4 -1.0

3. Delivery of tools to the

team Surgery

9.22

1.25

46.8

< 0.001

5 -1.32 6 0.21

3 4 Equipment relocation

7.4

1.12

46.8

< 0.001

4 -1.86 5 -1.55 6 3.1

5. Attach serum set 7.67

1.25

46.8

< 0.001

4 5 - 0.31 6 1.23

6. Patient relocation 16.14 1.43 46.8 < 0.001 5 6 1.54

Table 2. Comparison of average risk score in different tasks of scrub role and difference between

tasks Duties Average RBA

score Standard

deviation F- valu P- valu Difference between

two tasks

1. The surgical table set

up

5.0

1.2

18.01

< 0.001

1 2 0.47 3 - 0.86 4 0.71

5 -1.2 2. Prevent the surgical

table 4.43

1.1

18.01

< 0.001

2 3 -1.33

4 -1.2

5 -1.63 3. Delivery of tools

from Circulator

5.8 1.1

18.01

< 0.001

3

4 0.15

5 -0.3

4. Help the surgeon

5.61

1.3

18.01

< 0.001

4

5 -0.45

5. Deliver tool to work

room

6.1

1.2

18.01

< 0.001



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Table 3. Level of risk and priority level of corrective actions based on REBA score in different tasks

4. Discussion The new method of laparoscopy threatens the ergonomic conditions of surgical technologists

working as circulator and scrub. Based on the results, the level of risk for Circulator role was

obtained medium and high in each of its tasks. Therefore, implementing ergonomic interventions as

well as corrective actions should be taken into account. In a study carried out by Murty et. al.

(2010) on 12 endoscopic nurses working in five different tasks, using method, and after 26

observations it was found that the scores related to the back and neck regions in each task were high

or very high among the participants (Murty et. al., 2010). In another study in 2017, 62 surgeons, first

assistant and scrubs were evaluated by the RUlA method, and it was found that during the surgery

almost 95% of people had ergonomic problems among which 37.1% were at high risk (Pazouki et.

al., 2017). In our study, the highest risk score of 9.22 was for those participants working with foot

pedal. The reason is that foot pedal is located on the floor requiring the person bending trunk and

legs more than 90 degrees inducing a high risk of WMSDs (Figure 3). Although the patient

transplantation task allocated score of 6/14 which means being at a moderate level it received the

lowest score compared to the other tasks.

Figure 3. Participants working with foot pedal

Type of duty RBA

score

Danger level Priority level

corrective actions

The need for action

Correction and time

Bringing Surgery set and

Pack

7 Medium 2 Necessary

Opening sterile

instruments


Deliver the tool to the

surgical team

9 Top 3 Essential (sooner)

Equipment

relocation


Attach serum set

8 Top 3 Essential (sooner)

Patient relocation


the surgical table set up 5 Medium 2 Necessary

Prevent the surgical table 4 Medium 2 Necessary

Delivery of tools from the

circulator


Help the surgeon 6 Medium 2 Necessary

Deliver tool to work room 6 Medium 2 Necessary



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When transferring, the greatest amount of force exertion is concentrated on patient

Transferor. Most of the time, circulator holds only the patient's legs with a relatively acceptable

posture. However, if the Circulator is positioned on the patient's side, the arms are bent up to 45 to

90 degrees forward and the trunk is also bent more than 60 degrees which impose a high level of

risk to the person (Figure 4).

Figure 4. Transferring, the greatest amount of force exertion is concentrated on patient Transferor

The average risk score difference between the two tasks of pedal delivery and patient’s

transferring was the highest (P <0.001).After pedal delivery, CCD used by surgery team had the

highest risk score as the CCD was placed at the bottom of the laparoscopic cart slot at less than 500

mm from the floor that required the participants awkward postures to do the task (Figure 5).

Figure 5. CCD used by surgery team

Serum attachment is also associated with a high level of high serum holder (7.67 grade) and

an unpleasant postures of extension and neck rotation, deviation to the front of the arm exceeds 90

degrees, shoulder height, rotation, and extension of 0 to 20 degrees of trunk (Figure 6).



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Figure 6. Serum attachment is also associated with a high level of high serum holder

In front of the device, such as the setting of sialtic light (7/4 grade) Surgical technologist has

to raise more than 90 degrees of arm, Shoulder up, neck extension and the trunk and the unbalanced

position of the legs. This posture can be justified by the attachment of the light to the ceiling and its

height from the ground floor (Figure 7).

Figure 7. The setting of sialtic light

Figure 8. To remove cloth pack from the lower floor of the hallway



98

If using cloth pack (6900 g) the surgical technologist will have to remove it from the lower

floor of the hallway at an altitude of 230 mm from the floor which in this case faces a significant

change in posture (Figure 8).

The displacement of heavy dishes (6200 g) stored at high altitudes of the work room

encasement (1880 mm) is considered as one of the other ergonomic issues that the circulators were

encountered with (Figure 9).

Figure 9. The displacement of heavy dishes

Scrub was another role that the surgical technologist was responsible for. According to our

findings, the technologists in this role face a medium-risk (4-6) level. Abdullah Zadeh et. al. (2016) also

found similar results in his study so that the average score of RBA was 7.7 in three scrub activities

(Abdollahzade et. al., 2016). The greatest difference here was between the average risk scores obtained

for pulling the table and delivering the tool to the work room as the lowest score was related to the task

of pulling the surgery table. This finding can be due to the participants’ relatively better postures. In a

way that most participants try to approach tothe surgical bed (arm deviation forward up to 20 degrees)

with holding up trunk in a right posture (straight or bending 0 to 20 degrees) and sometimes slightly

bent (0 to 20 degrees) holding the hand in the middle of the table (no abduction of the arms before

surgery beginning. In this situation, the worst posture was observed in the wrist (abduction and

extensions up to 15 degrees). Noteworthy, sometimes the participants would approach to the table from

the side of the surgical bed requiring trunk to be twisted and bent 20 to 60 degrees, following by an

unbalanced position of the legs, abduction of the arms, an angle of less than 60 degrees for forearms and

the awkward posture of the wrists (Figure 10).

Figure 10. The displacement of heavy dishes



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In the delivery of tools to the work room although the level of risk is moderate but the

highest score is (6/1). At the end of surgery the scrub should put the tool in the sink of the work

room. Since the height of these sinks is low individual puts inside the sink one single instrument on

the surgical table with a rotating posture and bending 20 to 60 degrees trunk, unbalanced position of

the legs, deviation 45 to 90 degrees of arm (Figure 11).

Figure 11. At the end of surgery the scrub should put the tool in the sink of the work room

In the help to the surgeon as well although the trunk is almost in perpendicular position but

with an average risk level (5.61), it encounters ergonomic problems. Janki also believes in

Laparoscopy the neck and back are in the vertical position and static state (Janki et. al., 2017). In the

process of tools delivery to the work room, although the level of risk was moderate, the highest

score was obtained (6/1). At the end of surgery, the scrub was responsible for putting the tool in the

sink of the work room. Since the height of these sinks is low for most of the individuals, they put

the devices one by one inside the sink with a rotating posture with a 20 to 60 degree trunk bending,

unbalanced position of the legs, and an arm deviation of 45 to 90 degree (Figure. 11). Also, when

helping to the surgeon although the trunk was almost in perpendicular position, the average risk

level was obtained relatively high (5.61) Janki also believed that in Laparoscopy process the neck

and back may be in the vertical position and static state (Janki et. al., 2017). This can be explained

by the fact that surgical technologists simultaneously play the both roles of scrub and first assistant.

Pazuki also pointed out this issue in his study (Pazouki et. al., 2017). In case of presence only one

resident or surgeon, the technologist had to use simultaneously both the right and left hands,

respectively, to keep and adjust the camera to accurately transfer the field of surgery image to the

monitor with an average time of 4380 seconds and maintaining and tension tightening the grasper

for a good exposure for bile bladder with an average time of 2640 seconds. This condition caused

the technologist to get an unpleasant static posture due to ports limit which would increase the range

of motion to degree 4 (Bartnicka et. al., 2013). The grasper held the right or left hand with tensing it

on the right side of the patient where the monitor was located. In this case, two inappropriate

ergonomic conditions occur including to reduce the distance to the monitor (mm770) and neck

rotation and extension (Figure 12).



100

Figure 12. Surgical technologists simultaneously play the both roles of scrub and first assistant

Previous studies also showed that if the monitor was not in the proper position, extension,

bending and static neck rotation may occur. To deliver the tool to the surgeon may mostly require a

worse posture. Holding the camera with a hand or grasper and availability of the device on the

Mayo table forced the participants to rotate, bend trunk up to 20 to 60, stretching and abduction of

the arms, unbalanced position of the legs and the neck rotation and extension (Figure 13).

Figure 13. To deliver the tool to the surgeon may mostly require a worse posture

Research Constraints

In this study, the participation of male surgical technologists was very small as a result, the

results cannot be safely attributed to the male society. One of the advantages of this research is the

evaluation of individuals in a completely real and alive surgical condition and the imaging of a

point that is visible to all the angles.

5. Conclusion

The study was conducted for concern about the rapid growth of laparoscopy and the lack of

knowledge of ergonomic conditions in surgical technologists. Polling data and observations indicate

that there is a real problem in this population with a high level of prevalence of disorders. The roles

of both roles raise people with a moderate level of risk. Perhaps this risk is more in the role of a

circulatory. As a result, some challenges require new engineering solutions in equipment, Tools and

environment, and integration of ergonomics in educational curriculum to adapt the working



101

conditions to the individual's abilities and characteristics with the aim of increasing the safety,

productivity and job satisfaction of the employees.

Acknowledgement

The present paper is drawn from one of the parts of the master's thesis of the operating room

approved by the code 396858 at Isfahan University of Medical Sciences. Hereby, I express my

gratitude the Nursing and Midwifery Faculty for its collaboration in the research. Also, I thank the

Isfahan University of Medical Sciences and the research office for cooperating and funding.

References

Abdollahzade F, Mohammadi F, Dianat I, Asghari E, Asghari-Jafarabadi M, Sokhanvar Z. (2016).

Working posture and its predictors in hospital operating room nurses. Health promotion

perspectives. 6(1):17.

Athena RP, Elnaz RP, Marzieh P. .(2014).the effect of ergonomic principles on reducing the risk of

musculoskeletal disorders RULA in computer users. Quarterly journal of Iranian ergonomics

and human factors engineering. 3(1):25-30. ] Persian [

Attar SM. .(2014). Frequency and risk factors of musculoskeletal pain in nurses at a tertiary centre

in Jeddah, Saudi Arabia: a cross sectional study. BMC research notes. 7(1):61.

Ballester Arias A, García A. .(2017). Asociación entre la exposición laboral a factores psicosociales

y la existencia de trastornos musculoesqueléticos en personal de enfermería: Revisión

sistemática y meta-análisis. Revista Española de Salud Pública. 91(1):e1-e27.

Bartnicka J, Ziętkiewicz A, Kowalski G. .(2013).Analysis of selected ergonomic problems in the

use of surgical laparoscopic tools. Zeszyty Naukowe/Akademia Morska w Szczecinie.34

(106):19--26.

Bartnicka J, Zietkiewicz AA, Kowalski GJ. .(2018). Ergonomic study on wrist posture when using

laparoscopic tools in four different techniques regarding minimally invasive surgery.

International Journal of Occupational Safety and Ergonomics. 24(3):438-449.

Choi SD. (2018). A review of the ergonomic issues in the laparoscopic operating room. Journal of

Healthcare Engineering. 3(4):587-6.

Choi, S.H. (2015). Re-examining the Dimensionality of Leisure Motivation and Leisure Satisfaction

in a Multicultural Context: Evidence from Macau. Humanities & Social Sciences Reviews,

3(1), 06-10.

Choobineh A, Daneshmandi H, Fallahpour A, Rahimi Fard H. .(2012). ergonomic evaluation of the

risk of musculoskeletal disorders in employees of a petrochemical company. Health of Iran,.

10(3):80-90] .persian [

Choobineh A, Movahed M, Tabatabaie SH, Kumashiro M. .(2010). Perceived demands and

musculoskeletal disorders in operating room nurses of Shiraz city hospitals. Industrial

health. 48(1):74-84.

Choobineh AR, Daneshmandi, HadiPourf, Fard R, Hoda. .(2013).Ergonomic Evaluation of the Risk

of Musculoskeletal Disorders in Employees of a Petrochemical Company. Iranian

Occupational Health Journal. 10 (3): 78-88.

Chung Y-C, Hung C-T, Li S-F, Lee H-M, Wang S-G, Chang S-C, et. al.(2013).Risk of

musculoskeletal disorder among Taiwanese nurses cohort: a nationwide population-based

study. BMC musculoskeletal disorders.14(1):144.

Copenhaver MS, Friend TH, Fitzgerald-Brown C, Fernandez M, Addesa M, Cassidy J.

(2017).Improving operating room and surgical instrumentation efficiency, safety, and

communication via the implementation of emergency laparoscopic cholecystectomy and

appendectomy conversion case carts. Perioperative Care and Operating Room Management.

8:33-7.



102

Dalager T, Jensen P, Winther T, Savarimuthu T, Markauskas A, Mogensen O, et. al. .(2018).

Surgeons’ muscle load during robotic-assisted laparoscopy performed with a regular office

chair and the preferred of two ergonomic chairs: A pilot study. Applied ergonomics.

Dalager T, Søgaard K, Bech KT, Mogensen O, Jensen PT. .(2017).Musculoskeletal pain among

surgeons performing minimally invasive surgery: a systematic review. Surgical endoscopy.

31(2):516-26.

Dana, A., Hamzeh A. (2013). The Relationship between Religiosity and Athletic Aggression in

Professional Athletes, UCT Journal of Social Sciences and Humanities Research, 4, 01-05.

El-Badry A, Allam H, Marawan H. .(2018). Neck and upper limb pain among gynecologists

working at menoufia governorate in egypt. Egyptian Journal of Occupational Medicine.

42(1):123-32.

Epstein S, Sparer EH, Tran BN, Ruan QZ, Dennerlein JT, Singhal D, et. al. .(2018).Prevalence of

Work-Related Musculoskeletal Disorders Among Surgeons and Interventionalists: A

Systematic Review and Meta-analysis. JAMA surgery. 153(2):e174947-e.

Heba Ali Hassan A, Eglal Hassanein A-H. .(2018).The Effect of Ergonomics Program on Nurses'

Knowledge and Practice in Operating Room. Journal of Nursing and Health Science ( IOSR-

JNHS). 7(1):6-15.

Janki S, Mulder EE, IJzermans JN, Tran TK. (2017).Ergonomics in the operating room. Surgical

endoscopy. (2017). 31(6):2457-66.

King CA. .(2011).Health care worker safety in surgery. AORN journal. 94(5):457-68.

Kramp KH, van Det MJ, Totte ER, Hoff C, Pierie J-PE.(2014). Ergonomic assessment of the French

and American position for laparoscopic cholecystectomy in the MIS Suite. Surgical

endoscopy.28 (5): 1571-8.

Munabi IG, Buwembo W, Kitara DL, Ochieng J, Mwaka ES. (2014). Musculoskeletal disorder risk

factors among nursing professionals in low resource settings: a cross-sectional study in

Uganda. BMC nursing. 13(1):7.

Murty M. (2010). Musculoskeletal disorders in endoscopy nursing. Gastroenterology

Nursing.;33(5):354-61.

Nur Azma B, Rusli B, Oxley J, Quek K.(2016).Work related musculoskeletal disorders in female

nursing personnel: prevalence and impact. International Journal of Collaborative Research

on Internal Medicine and Public Health. 8(3):294-98.

Nützi M, Koch P, Baur H, Elfering A. .(2015).Work–Family conflict, task interruptions, and

influence at work predict musculoskeletal pain in operating room nurses. Safety and health

at work. 6(4):329-37.

Pazouki A, Sadati L, Zarei F, Golchini E, Fruzesh R, Bakhtiary J.(2017).Ergonomic Challenges

Encountered by Laparoscopic Surgeons, Surgical First Assistants, and Operating Room

Nurses Involved in Minimally Invasive Surgeries by Using RULA Method. Journal of

Minimally Invasive Surgical Sciences. 6 (4).p:344-6

Sánchez-Margallo JA, Sánchez-Margallo FM.(2017).Initial experience using a robotic-driven

laparoscopic needle holder with ergonomic handle: assessment of surgeons’ task

performance and ergonomics. International journal of computer assisted radiology and

surgery. 12(12):2069-77.

Stolt M, Miikkola M, Suhonen R ,Leino-Kilpi H. .(2018).Nurses’ Perceptions of Their Foot Health:

Implications for Occupational Health Care. Workplace health & safety. 2018;66(3):136-43.

Supe AN, Kulkarni GV, Supe PA. .(2010).Ergonomics in laparoscopic surgery. Journal of minimal

access surgery. 6(2):31.

Szeto G, Wong T, Law R, Lee E, Lau T, So B,.(2013). The impact of a multifaceted ergonomic

intervention program on promoting occupational health in community nurses. Applied

ergonomics. 44(3):414-22.

Taghinejad H, Azadi A, Suhrabi Z, Sayedinia M. .(2015).Musculoskeletal disorders and their related

risk factors among iranian nurses. Biotechnology and Health Sciences. 3(1).



103

Wang R, Liang Z, Zihni AM, Ray S, Awad MM. .(2017).Which causes more ergonomic stress:

Laparoscopic or open surgery? Surgical endoscopy. 31(8):3286-90.

Wasielewski A.(2017). Guideline implementation: minimally invasive surgery, part 1 .AORN

journal.106(1):50-9.

Zamanian Z, Norouzi F, Esfandiari Z, Rahgosai M, Hasan F, Kohnavard B. .(2017). Assessment of

the prevalence of musculoskeletal disorders in nurses. Armaghane danesh. (10):976-86.

Zhang Y, Duffy JF, de Castillero ER, Wang K. .(2018). Chronotype, Sleep Characteristics, and

Musculoskeletal Disorders Among Hospital Nurses. Workplace health & safety;66(1):8-15.

a comparative study on the risk factors of musculoskeletal

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